Provider Demographics
NPI:1053066399
Name:ANDERSON, JORDAN LILLIAN (PA-C)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:LILLIAN
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10150 NIAGARA LN N # 100
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-7588
Mailing Address - Country:US
Mailing Address - Phone:224-213-5886
Mailing Address - Fax:
Practice Address - Street 1:10150 NIAGARA LN N # 100
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-7588
Practice Address - Country:US
Practice Address - Phone:224-213-5886
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-15
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA15644363A00000X
MN14483363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant